Cognitive Behavioral Therapy for Psychosis in Clinical Practice

PRACTICE REVIEW

Cognitive Behavioral Therapy for Psychosis in Clinical Practice

Harry J. Sivec and Vicki L. MontesanoNortheast Ohio Medical University

Across two continents, Cognitive–Behavioral Therapy for Psychosis (CBT-P) has been endorsed as anadjunctive treatment for individuals who experience persistent positive symptoms of schizophrenia. Themoderate effect sizes reported in early studies and reviews were followed by better controlled studiesindicating more limited effect sizes. This article provides a review of the literature that addresses theeffectiveness of CBT-P, including particular areas of emphasis and practice elements associated with thisapproach. In addition, because the majority of research on CBT-P has been performed in the United Kingdom,implications for implementation and sustainability of this practice in the United States are presented.

Keywords: cognitive behavioral therapy, psychotic symptoms, psychosis, schizophrenia

Finding the “right” treatment for schizophrenia has been the elusivehope of many individuals, families, and health care providers. Al-though antipsychotic medications have demonstrated significant ben-efits for many individuals who experience psychotic symptoms, manymore continue to report distressing symptoms. According to Gould,Mueser, Bolton, Mays, and Goff (2001), the number of individualswho continue to experience persistent psychotic symptoms, despitetaking medication, varies between 25% and 50%.

Various forms of psychosocial treatments have been applied toease the distress of psychotic symptoms that are unresponsive tomedication. One form of therapy that has shown some promise iscognitive–behavioral therapy for psychosis (CBT-P). Over thepast decade, there has been a resurgence of interest in the use ofcognitive–behavior therapy, which is widely used for anxiety anddepression, for psychotic symptoms. However, most of the re-search conducted in the area of CBT-P has mainly emerged fromthe United Kingdom (Wykes, Steel, Everitt, & Tarrier, 2008).

The focus of this article is to review the literature that addresses theeffectiveness of CBT-P. We also review particular areas of emphasis(e.g., hallucinations and delusions) and practice elements associatedwith this approach (e.g., formulation). Finally, for clinicians practic-ing in the United States, we consider factors that influence the im-plementation and sustainability of this form of treatment in the UnitedStates. Within this review, in order to differentiate Cognitive–Behavioral Therapy (CBT) for different diagnoses (e.g., depression,anxiety, psychosis), studies that use Cognitive–Behavioral Therapyfor Psychosis will be referred to as CBT-P.

Effectiveness of CBT-P for the Treatment of PositivePsychotic Symptoms

In both the United States and the United Kingdom, CBT-P isrecommended as an adjunctive treatment for individuals whoexperience persistent positive symptoms of schizophrenia (seeSchizophrenia PORT guidelines; Dixon et al., 2010; NICE clinicalguideline; National Collaborating Centre for Mental Health, 2009).The basis for this decision rests on a wide range of controlledresearch studies. The number of studies is so large that severalmeta-analyses have been conducted to discern and summarize thestate of this form of treatment. In preparing for this review, weidentified seven meta-analyses (Gould et al., 2001; Lynch, Laws,& McKenna, 2010; Pfammatter, Junghan, & Brenner, 2006; Pill-ing et al., 2002; Rector & Beck, 2001; Wykes et al., 2008;Zimmerman, Favrod, Trieu, & Pomini, 2005) that reviewed the useof CBT-P for individuals with schizophrenia.

Meta-analytic procedures offer a simple metric, the effect size,by which to measure the relative benefits of a given therapycompared with a variety of control conditions. In general, theeffect sizes are calculated using outcome measures that tend toreflect overall symptoms (i.e., at times including all symptomscombined and at other times separating symptoms into categories).The majority of studies examined in the meta-analyses focused onpositive symptoms (e.g., hallucinations and delusions), and allstudies included clients who were concurrently treated with anti-psychotic medications.

Due to differences in research methodologies between researchstudies, results of meta-analytic reviews have varied in the effectsizes reported for CBT-P. However, with the exception of Lynchet al. (2010), the majority of reviews have been favorable (King-don, 2010). For example, Rector and Beck (2001), in one of theearliest reviews of controlled studies of CBT-P (compared toroutine care), reported an average effect size of d � 1.31 forpositive symptoms. Since that time, several additional meta-analyses have been conducted and have reported more modesteffect sizes. For example, Wykes et al. (2008) reported a meanweighted effect size (Smith and Glass’s delta procedure-described

Harry J. Sivec and Vicki L. Montesano, Best Practices in SchizophreniaTreatment (BeST) Center, Department of Psychiatry, Northeast Ohio Med-ical University.

This research was supported in part by a grant to the BeST Center fromThe Margaret Clark Morgan Foundation.

Correspondence concerning this article should be addressed to Harry J.Sivec, PhD, Best Practices in Schizophrenia Treatment (BeST) Center,Department of Psychiatry, Northeast Ohio Medical University, 4209 StateRoute 44, P.O. Box 95, Rootstown, OH 44272. E-mail: [email protected]

Psychotherapy © 2012 American Psychological Association2012, Vol. 49, No. 2, 258–270 0033-3204/12/$12.00 DOI: 10.1037/a0028256

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in Gould et al., 2001) of 0.399 (n � 24 studies) favoring CBT-Pwhen delivered by individual clinicians for positive symptoms.

Based on a review of the above meta-analyses, three factorsappear to influence the outcome of studies: (a) procedures relatedto raters who are blinded to group assignment; (b) the inclusion ofa follow-up assessment several months after the posttreatmentassessment; and (c) the inclusion of an active control group (e.g.,supportive counseling, Befriending).

The first factor, procedures related to raters who are blinded togroup assignment, focuses on whether raters who conducted out-come assessments were aware of group placement. In their meta-analysis, Zimmerman et al. (2005) reported an effect size (g) of .35for 14 studies that examined the impact of CBT-P on positivesymptoms. However, they noted a smaller effect size for studiesthat used masking procedures (g � .29) compared with studies thatdid not use masking procedures (g � .54). Zimmerman et al.(2005) noted that an independent sample t test “revealed that thedifference between unbiased ES from blinded and unblinded trialsis nonsignificant” (p. 6). Similar to Zimmerman et al. (2005), Wykeset al. (2008) noted differences in magnitude of effect size for studiesthat were masked (� � .307) compared with studies that were un-masked (� � .492). Taking into account the use of blinded or maskedassessment, both meta-analyses suggest a mean effect size roughlyaround .30. Using Cohen’s (1988) benchmarks (.20 is small, .50 ismedium, and .80 is large), this estimate is a small effect size.

The second factor that appears to influence the outcome ofstudies involves the use of a follow-up assessment several monthsafter the active treatment phase is finished. Some studies (e.g.,Durham et al., 2003) have reported minimal or no differencebetween CBT-P and active control conditions at the end of treat-ment (e.g., d � �.06 [Positive and Negative Syndrome Scale(PANSS); Kay, 1991] in Durham et al., 2003) but report a signif-icant benefit for CBT-P at extended follow-up (d � .32 favoringCBT-P on the PANSS; Kay, 1991). In contrast, another study(Valmaggia, Van Der Gaag, Tarrier, Pijnenborg, & Sloof, 2005)reported significant benefits of CBT-P at the end of treatment (e.g.,physical characteristics of hallucinations, d � .75), but not atfollow-up (physical characteristics of hallucinations, d � .26)relative to supportive counseling.

In an effort to identify more general trends, the Zimmerman etal. (2005) meta-analysis reported on 11 studies that provided anextended follow-up assessment. Their analyses identified effectsizes ranging from .40 for early follow-up (�12 months) to .33 forstudies with a later follow-up (�12 months). Similarly, Pfammat-ter et al. (2006) reported an effect size of g � .39 (n � 9 studies)for positive symptoms assessed at follow-up favoring CBT-P. Ofthe more recent meta-analyses, neither Lynch et al. (2010) norWykes et al. (2008) included long-term follow-up assessment in

their reviews. However, Lynch et al. (2010) cited the NICE clinicalguidelines (National Collaborating Centre for Mental Health, 2009)that found effect sizes for CBT-P versus active controls to be .18 at 12months (five studies) and .08 at 24 months (three studies).

The third factor that appears to influence the outcome ofstudies focuses on the inclusion of an active control group (e.g.,supportive counseling, Befriending). Ideally, clients enrolled inan active therapy control group would receive a similar dose(i.e., amount of contact with a clinician) as well as supportivetherapeutic interactions (e.g., focusing on acceptance, empathy,positive social interaction). Overall, clients received an inter-vention designed to account for what is often referred to asnonspecific therapeutic factors (see Tarrier & Wykes, 2004 fora discussion). As a result, the control condition is more of anactive comparison as opposed to a neutral placebo. Lynch et al.(2010) conducted a meta-analysis that included only studieswith an active control group and focused on assessment out-comes at the end of active treatment as defined by the author(s)of the study. Using these criteria, they reported an effect size (g)of �.19 (favoring CBT-P) for eight studies that examined theimpact of CBT-P on positive symptoms relative to an activecontrol group. When Lynch et al. (2010) removed the twostudies that did not include masking procedures, the effect sizefor the six blinded studies dropped to �.08 (favoring CBT-P).Kingdon (2010) criticized the Lynch et al. (2010) findingsbased on the exclusion of pertinent studies. A case in point,Wykes et al. (2008) reported a mean effect size of (delta) .22favoring CBT-P for studies (n � 12) that included controlgroups accounting for nonspecific effects of therapy (as well asmeeting other qualities of methodological rigor defined by theClinical Trial Assessment Measure; Tarrier & Wykes, 2004).

In summary, CBT-P for positive symptoms of psychosisdemonstrates a modest but significant positive impact (averageeffect around .35–.40) in controlled studies. When comparedwith an active therapy control, the benefits of CBT-P aresomewhat limited (average effect around .20). This reducedeffect may speak to a larger discussion related to the relativelycomparable effectiveness of psychological interventions (seeWampold, 2007), with reference to a variety of common factorscontributing to the effect. For the purpose of this review, weview the aforementioned data as supporting the position thatCBT-P specifically and perhaps psychological therapy in gen-eral, provides modest benefit, beyond medication effects, forthose who struggle with persistent positive symptoms of psy-chosis. In this category, CBT-P is the most developed andrigorously tested individual psychological therapy designed toaddress symptoms of psychosis. See Table 1 for summary ofeffect sizes (d/g) for CBT-P with positive symptoms.

Table 1Summary of Benefits of CBT-P on Positive Symptoms (Mean Effect Size d/g)

Individual CBT-p studies (n � 24) .399a

Rigorous studies (high CTAM rating, n � 12) .22a

Active therapy control studies only (n � 8) –.19 (favoring CBT-P)b

Long-term follow-up .40 (�12 months); .33 (�12 months)c

Long-term follow-up (active therapy control only) .18 (12 month); .08 (24 month)b

a � Wykes, et al., (2008). b � Lynch et al., (2010). c � Zimmerman, et al., (2005).

259CBT-P IN CLINICAL PRACTICE

CBT-P and Relapse Prevention

A number of studies have examined the effects of CBT-P onrelapse prevention. Across studies, relapse prevention has beendefined somewhat differently. For example, Pilling et al. (2002)examined six studies and found there was variance in the way thatrelapse was defined between studies, ranging from hospital read-mission to a deterioration equivalent of five or more on the BriefPsychiatric Rating Scale (BPRS; Overall & Gorham, 1962). Sim-ilarly, Lynch et al. (2010) reviewed studies of CBT-P, in whichrelapse was defined as either a change in care, hospitalization, oran increase in positive symptoms within a specified time period.Both reviews reported that there was no evidence that CBT-Pprevented relapse. Kingdon (2010) challenged the Lynch et al.(2010) results based on inclusion/exclusion of particular studies.

Some studies have looked specifically at relapse as defined byreadmission to the hospital and reported positive results. Forexample, in a comparison of CBT-P with treatment as usual,Turkington et al. (2006) looked at relapse risk as defined byreadmission to the hospital. At 12-month follow-up, they found ahigher (chi-square significant at .05) readmission rate in the TAUgroup (23%) compared with CBT-P (14%). They also reported thatthe CBT-P group had a longer time to readmission compared withTAU (odds ratio 1.84), and spent significantly less time in thehospital if they relapsed (p � .05). In contrast, other studies foundno significant differences in rehospitalization rates comparingCBT-P with standard treatment control group (Kuipers et al.,1998) or supportive counseling (Tarrier et al., 2004) at 18-monthfollow-up.

There is some indication that receiving CBT-P before a hospitaladmission may lead to fewer days in the hospital. Reviewingoutcomes for clients receiving services 24 months posttreatment,Malik, Kingdon, Pelton, Mehta, and Turkington (2009) analyzeddata pertaining to duration of stay for rehospitalization and foundsignificant (p � .05) differences favoring CBT-P (mean dura-tion � 32.7 days) compared with TAU (mean duration � 48.9).Kuipers et al. (1998) found a similar, nonsignificant trend in their18-month follow-up when comparing CBT-P (mean inpatientdays � 14.5) to a standard treatment only group (mean inpatientdays � 26.1).

Of note, the intervention reviewed in Malik et al. (2009) was arelatively low “dose” (six sessions) trial and delivered by nonex-perts in CBT-P. It is also important to note that some familymembers of clients enrolled in the study met with treatmentproviders three times during the course of the study in order toassist with issues like case formulation, psychotic symptom man-agement, and preventing relapse. This study increases the possi-bility that including interventions for family members may provideadditional benefits for clients treated with CBT-P.

Overall, CBT-P does not confer an advantage to relapse pre-vention when defined broadly. When relapse prevention is morenarrowly defined as rehospitalization, studies are mixed in out-comes. Therefore, the role of CBT-P in reducing the rate ofrehospitalization requires further investigation. If replicated, thefinding that clients who have received CBT-P before readmission(compared with those receiving TAU or standard care) may spendless time in the hospital if readmitted, has both clinical andeconomic implications.

CBT-P and Specific Symptoms

Hallucinations

Overall findings indicate that CBT-P does positively impacthallucinations on several dimensions (e.g., reduces hallucinations,decreases severity) at the end of treatment. However, long-termimpact of CBT-P is unclear. For example, Pfammatter et al. (2006)reported that CBT-P leads to a reduction in hallucinations atcompletion of therapy (g � .34, n � 6 studies), but reported thatthe gain is often lost at follow-up (which generally varies between6 and 12 months across studies). This pattern of results wasreported in the following studies: Shawyer et al. (2012); Trower etal. (2004); and Valmaggia et al. (2005).

Tarrier et al. (2001) intensively examined data from the Tarrieret al. (1998) randomized control trial including only patients (N �42) who reported both hallucinations and delusions. The authorsreported that change in severity of hallucinations at the end oftreatment was significantly greater for CBT-P relative to support-ive counseling in post hoc comparisons (using nonparametric tests,p � .05). However, the data used to arrive at this conclusion restedon a single item (7-point scale) from the BPRS (Lukoff, Liber-mann, & Nuechterlein, 1986).

Jenner, Nienhuis, Wiersma, and Van De Willige (2004) addedother interventions to CBT-P (i.e., coping training, motivationalinterviewing techniques, family treatment, rehabilitative efforts,mobile crisis, and medication) to form what they called Halluci-nation Focused Integrative Treatment. Results from their work,with this approach, suggested significant improvements on Psy-chotic Symptom Rating Scales (PSYRATS, Haddock, McCarron,Tarrier, & Faragher, 1999) distress ratings for voices (d � .62) andtotal burden (d � .55) as well as positive symptom ratings on thePANSS (Kay, 1991; d � .71) compared with the routine carecondition. Wiersma, Jenner, Nienhuis, and Van De Willige (2004)also reported significant improvements in quality of life and socialrole functioning (d � .64) favoring integrated treatment. Of note,this more comprehensive and integrated approach (of whichCBT-P is a strong component) maintained benefits at 18-monthfollow-up on the PSYRATS (Haddock et al., 1999) distress (d �.60), total burden (d � .51), and the PANSS (Kay, 1991) positivesymptoms (d � .45; Jenner, Nienhuis, Van De Willige, & Wi-ersma, 2006).

The general trend suggests that CBT-P for hallucinations showsbenefits at the end of treatment, but benefits tend to be lost atfollow-up in many, but not all, studies. The active therapeuticagent that contributes to short-term change during treatment isunclear. However, treatment that incorporates other therapeuticelements (e.g., family involvement, coping skills) may be impor-tant to maintenance of gains with regard to hallucinations (seeJenner et al., 2006).

Delusions

Although Pfammatter et al. (2006) reported that the impact ofCBT-P on hallucinations was demonstrated at posttreatment andthen lost at follow-up, their review of studies, looking at the impactof CBT-P on delusions, did not show an effect until follow-up (g �.47 at follow-up, n � 5 studies). In one study, Durham et al. (2003)compared the impact of CBT, supportive psychotherapy, and treat-

260 SIVEC AND MONTESANO

ment as usual in a routine practice setting. In this study, bothCBT-P and supportive therapy failed to show significant change atposttreatment on the PSYRATS (Haddock et al., 1999) delusionscale, but both groups showed significant within-group benefits at3-month follow-up (CBT-P d � .83; SPT d � .78). There were nosignificant changes at either posttreatment or follow-up for clientsin the TAU group.

Haddock et al. (2009) compared CBT-P with social activitytherapy to determine impact on aggressive behavior. According tothe authors, the presence of anger and delusional symptoms appearto be correlated with violence and aggression. Individuals in theCBT-P group had a lower number of total aggressive incidentsduring treatment and a lower number of physically aggressiveincidents at follow-up. The authors noted that “there was a rela-tively large decrease on the PSYRATS (Haddock et al., 1999)delusions factor of ‘distress’ in the CBT-P group compared to aslight increase in the SAT (social activity therapy) group (p. 156).”They speculated that the impact on delusions may have been apivotal factor in reducing violence. Of note, significant meandifferences between groups in delusions were noted at posttreat-ment favoring CBT-P (d � .93), but, in contrast to the trend notedearlier, no significant differences were found at follow-up (approx-imately 6 months later, d � .096).

There are a variety of studies that were conducted in routineclinical practice settings that offer additional perspectives onCBT-P and delusions. Jakes, Rhodes, and Turner (1999) offered acombination of solution-focused therapy and CBT-P for delusions(mainly persecutory) in routine clinical practice to 18 clients. Inthis small study, approximately one-third of clients improved (i.e.,significant decrease in conviction, preoccupation, and anxiety),one-third showed no change, and one-third were somewhere be-tween the other groups. The overall change in median convictionrating over time was significant at p � .01. The authors offered apractical suggestion, stating that if the client shows no change inconviction within three sessions, the therapist may need to con-sider focusing on another treatment area. Morrison et al. (2004)similarly evaluated the use of CBT-P in routine practice (i.e.,community mental health center). Clients were allocated to wait-list/TAU control or CBT-P based on the availability of the relevantclinician (i.e., not randomized, but naturalistic allocation). Theyreported significant improvements in the PSYRATS (Haddock etal., 1999) delusions total score at posttreatment (d � .54) favoringCBT-P compared with Wait-list/TAU.

Negative Symptoms

The negative symptoms of schizophrenia include flat affect(reflected in an expressionless face and monotone voice), alogia(slowed responses to questions, “poverty of speech”), and avoli-tion (inability to initiate and sustain goal-directed activities). Acognitive–behavioral model of interventions has been developedfor negative symptoms (Rector, Beck, & Stolar, 2005). Althoughnegative symptoms have been linked to biological factors contrib-uting to neurocognitive deficits, the cognitive–behavioral perspec-tive focuses on the role that negative beliefs/assumptions have onthe resulting withdrawal and disengagement behaviors. The basicpremise is that individuals with schizophrenia disengage fromactivities for two primary reasons: (a) in response to positivesymptoms (so called secondary negative symptoms, also referred

to as safety and avoidance behaviors) to cope with distressingdelusional beliefs, perceived threats, voices, and so forth, and (b)as a self-protective, compensatory response to negative expecta-tions about performance (e.g., anticipating repeated failures intasks) and lack of anticipated pleasure in activities (Rector et al.,2005). Consistent with this view, Deegan (1997) provides a per-sonal and stirring depiction of negative symptoms as a “hardenedheart” that serves to protect the person from repeated failings bynot trying. She writes:

Giving up was not a problem, it was a solution. It was a solutionbecause it protected me from wanting anything. If I didn’t wantanything, then it couldn’t be taken away. If I didn’t try, then Iwouldn’t have to undergo another failure. If I didn’t care, then nothingcould hurt me again. My heart became hardened (p. 77).

Grant and Beck (2009) empirically investigated the relationshipbetween a constellation of negative expectancies they termed “de-featist beliefs,” cognitive impairment, and negative symptoms.They reported that defeatist belief endorsement mediated the re-lationship between cognitive impairment and both negative symp-toms and functioning. In other words, the presence and severity ofdefeatist beliefs helps to explain the relative expression of negativesymptoms. The resulting model also provides a potential target forcognitive therapy, holding some promise of exerting a positiveinfluence on the impact of negative symptoms.

Drawing from this model, Perivoliotis and Cather (2009) pro-vided an extensive case illustration of using a cognitive model andinterventions to treat negative symptoms. In their model, CBT-P ofnegative symptoms emphasizes setting realistic goals, employingexercises designed to disconfirm dysfunctional beliefs, and iden-tifying ways to work with low energy and engagement difficulties.

Preliminary reports showed promising results for the use ofCBT-P with negative symptoms compared mainly to routine care.For example, in their review, Wykes et al. (2008) reported a meanweighted effect size � .437 (n � 23 studies). A recent study byGrant, Huh, Perivoliotis, Stolar, and Beck (2012) confirmed thisfinding, showing that CBT-P for negative symptoms was associ-ated with significantly greater improvement (relative to standardcare) on the avolition-apathy scale of the SANS (Andreasen, 1981)after 18 months of treatment (between group d � �.66 favoringCBT-P). However, the advantage of CBT-P over active controltherapies has not been demonstrated across the majority of studies(see Lynch et al., 2010, n � 7 studies, with comments fromKingdon, 2010). Considering long-term effects of CBT-P on neg-ative symptoms, Turkington et al. (2008) reported significantlyfewer negative symptoms (SANS, Andreasen, 1981) within theCBT-P cohort at 5-year follow-up compared with the Befriendingcondition cohort (d � .55).

CBT-P: Acute Phase of Psychosis

The benefits of CBT-P during an acute psychotic episode aredifficult to study for a number of reasons. During an acute psy-chotic episode, medication is the typical front-line treatment forhelping to alleviate psychotic symptoms, and most patients admit-ted to the hospital are given antipsychotic medication. As such,studies of CBT-P versus TAU likely reflect the benefits of CBT-Pplus medication relative to medication alone. In their meta-analysis, Zimmerman et al. (2005) reported a medium effect size


(mean ES g � .57) from studies examining the impact of usingCBT-P during an acute psychotic episode. However, the authorsnoted that methodological limitations (e.g., lack of raters who wereblinded to group assignment) may have inflated the level ofimpact.

As an example, in one study reviewed by Zimmerman et al.(2005), Drury et al. (1996a) randomly allocated psychiatric inpa-tients to either CBT-P (individual and group, as well as familyengagement) or control group (informal support and recreationalactivities). Both groups showed a significant reduction in positivesymptoms at 12 weeks following admission, with the CBT-P groupshowing a significantly greater decline in symptoms in a shorteramount of time compared with the control condition (betweengroups effect size was 1.49 at week 7 and 1.23 at week 12). Bothgroups also showed declines in disorganized thinking and negativesymptoms at 12 weeks with no significant differences betweengroups (d � �.002, d � .18, respectively). At 9-month follow-up,the CBT-P group continued to show significantly fewer positivesymptoms (d � .71). No significant differences were found be-tween groups at 9-month follow-up for negative symptoms ordisorganization.

In a follow-up analysis, Drury et al. (1996b) found a more rapidresolution of psychotic symptoms at 6-months based on variousdefinitions of recovery (see also Lewis et al., 2002). Recovery timewas reduced by 25% to 50% depending on the definition of recovery.A survival function using the clinical recovery criteria found thecumulative proportion failing to recover to be .4 for CBT-P and .75for the control group. Factors that complicated the results of this studyincluded (a) raters not completely blinded to group assignment and (b)patients who also received a family engagement component, which isdifferent from most trials involving CBT-P.

Startup, Jackson, and Bendix (2004) compared CBT-P to TAUfor treatment during the acute phase. They found significant mul-tivariate differences between groups at 12-month follow-up favor-ing CBT-P (no difference at 6-month follow-up). They reportedthat a significantly larger proportion of clients in the CBT-P group(60%) showed reliable and clinically significant improvementcompared with TAU (40%). However, the study was also limitedby the lack of raters who were blinded to group assignment.

Looking at first episode psychosis, Jackson et al. (2008) com-pared CBT-P to Befriending during an acute psychotic episode.They reported potential significant benefits for CBT-P over Be-friending early in the treatment process (standardized mean differ-ence effect sizes were calculated as follows: .23 for positivesymptoms and .28 for negative symptoms), but no significantdifferences between groups at follow-up.

At present, findings on the benefits of CBT-P during an acutepsychotic episode are generally positive with modest effect sizes.Some studies show stronger effects on positive symptoms (Druryet al., 1996a) and others show more limited results (Jackson et al.,2008). Additional rigorously controlled trials of CBT-P deliveredduring an acute psychotic episode are necessary to help determineif this approach expedites the process of recovery (Drury et al.,1996a and 1996b; Jackson et al., 2008; Lewis et al., 2002) and/orassists with the maintenance of gains to slow the process ofreadmission (Turkington et al., 2006; Malik et al., 2009). Althoughthe duration of hospitalization was not significantly less for CBT-Pcompared with supportive counseling during an acute psychoticepisode, (Haddock, Tarrier, Morrison, et al., 1999; Lewis et al.,

2002) further investigation into the duration of hospitalization forthose who receive CBT-P interventions before readmission may bewarranted (Malik et al., 2009).

Perception of CBT-P by Individuals With PersistentPsychotic Symptoms

Several authors have reported that CBT-P is well-received byclients. Positive findings regarding satisfaction with CBT-P werereported in controlled trials by Kuipers et al. (1997) and Turking-ton et al. (2002). Two studies (Durham et al., 2003; Farhall,Freeman, Shawyer, & Trauer, 2009) conducted in routine clinicalpractice also reported high levels of patient satisfaction withCBT-P. According to Durham et al. (2003), when asked to rate iftreatment was positive and helpful, 70% in the CBT-P group rated“yes, definitely” compared with 37% in the supportive therapygroup and 30% in the treatment as usual condition (significant atp � .05). The specific reasons for high satisfaction ratings forCBT-P are unclear; however, according to Durham et al. (2003),patient perception of suitability of treatment may have influencedsatisfaction.

Predictors of Good Response to CBT-P:Client Variables

Although there are limited data, some factors appear to predicta better response to CBT-P. For example, Naeem, Kingdon, andTurkington (2008) reviewed data from two separate randomizedcontrolled trials (i.e., Sensky et al., 2000 and Turkington et al.,2002) and examined a variety of potential predictors of goodoutcome with CBT-P. They found that higher levels of insight(David, Buchanana, Rees, & Almeida, 1992) and a high CPRSglobal impression (higher distress/symptoms) score predicted goodoutcome in the study group that received brief CBT-P. Lookingonly at the data from the Turkington et al. (2002) study, Brabban,Tai, and Turkington (2009) found that positive response (opera-tionally defined as 25% or greater improvement in overall symp-toms and insight) to a brief form of CBT-P treatment was associ-ated with gender (female) and lower levels of delusionalconviction. The latter finding is consistent with results reported byGarety et al. (1997) in which clients who endorsed that they could“possibly be mistaken about their beliefs” (on the BPRS assess-ment measure) proved to be a predictor of improvement for thosewho expressed delusions.

In sum, distress (defined as higher number of symptoms), someawareness of deficits (insight), and lower conviction in beliefs (asdemonstrated by more flexibility in thinking to allow for alterna-tive explanations) are associated with a good response to CBT-P.In addition, women appear to show a better response to brieferforms of CBT-P, but the mechanism of action is unclear.

Strategies Used in CBT–P

Rector and Beck (2001) provide a concise summary of theshared goals and subtle variations of the different CBT-P ap-proaches described in the literature (see Table 2). There are cur-rently several textbooks available that partially serve as treatmentmanuals for delivering CBT-P. The manuals are quite similar;however, some authors emphasize different points such as a nor-


malizing rationale (Kingdon & Turkington, 1994, 2005); copingskills (Tarrier, Harwood, Yusopoff, Beckett, & Baker, 1990),self–other evaluative beliefs (Chadwick, Birchwood, & Trower,1996), and the use of formulation and a combination of techniques(Beck, Rector, Stolar, & Grant, 2009; Fowler, Garety, & Kuipers,1995; Nelson, 2005). As a result of these foundational techniques,new approaches have been proposed for treating psychosis, includ-ing Mindfulness and Meta-Cognitive approaches, CompassionateMind Training, and Acceptance and Commitment Therapy (seeTai & Turkington, 2009, for a review). What follows below is abrief and somewhat subjective review of elements of CBT-P thatwe believe differ from standard CBT. We draw from our clinicalexperiences as treatment providers who are familiar with standardCBT and have worked with individuals who are experiencingpsychotic symptoms for years before learning this particular ap-proach. We provide examples of ways to use some of the tech-niques that are discussed in an effort to convey the general char-acteristics of this approach. The following discussion is not meantto be an exhaustive review.

Engagement/Forming a Therapeutic Alliance

One feature that is common to all CBT-P textbooks is thespecial attention paid to developing a therapeutic relationship with

individuals who experience symptoms of psychosis. This is notsurprising given the widely acknowledged challenges to engagingclients who struggle with positive and negative symptoms ofpsychosis. For individuals diagnosed with schizophrenia, relation-ships with others can be experienced as difficult for a variety ofreasons (e.g., paranoia, cognitive difficulties, intrusive voices).Chadwick et al. (1996) offer recommendations that focus on min-imizing difficulties in the therapeutic relationship that includescheduling shorter, more frequent sessions, creating a less formalatmosphere at the start of therapy, structuring sessions to avoidextended silence, and refraining from pushing the client to chal-lenge delusional ideas before he or she is ready.

Stepping away from the research, we reflected on our expe-riences with providing therapy to individuals diagnosed withschizophrenia before learning the modified form of CBT. Theprimary differences seemed to revolve around the perspectiveof the clinician toward psychotic symptoms and the approach toworking with the client. By definition, psychotic experiencesand beliefs are outside of what most people believe or experi-ence. In addition, the connection between psychotic symptoms(e.g., content) and life experiences often do not make sense.Kingdon and Turkington (2005) define this as “Coping withincomprehensibility” (p. 50).

Table 2Shared Goals and Subtle Variations of The Different CBT-P Approaches

Definition Possible example

Establishing a strong therapeutic alliance Support, collaboration and acceptance are thehallmarks of a strong therapeutic alliance.With psychosis (specifically paranoia),developing trust may take time but ispivotal to engagement. Checkunderstanding regularly during sessions,ask the client for clarification if needed.

“I understand that you feel that it is difficultto trust. Please tell me how our worktogether can be the most helpful to you.”Or, if the clinician believes that the clientis suspicious of him or her: “It seems likeyou may not trust me. Can we talk aboutit?”

Education about the illness Education would include information basedon the biopsychosocial (i.e., biological,psychological, and sociological) modelwith a goal of normalizing the experienceand reducing stress. It is also important todiscuss the roles of vulnerability andstress.

“Many times, when people are under stress,symptoms get worse and coping strategiesjust don’t seem to work. They may feellike other people are talking about themor watching them.”

Cognitive and behavioral strategies for reducingstress directly related to hallucinations anddelusions

Identify thoughts and behaviors that maintaindistress and offer alternative explanations.

“You have talked about how when you startthinking about the evil spirits, you getupset. Have you had the chance topractice the other thoughts that we havediscussed? If not, let’s think of ways youcan start using them.”

Teach specific distraction or focusingstrategies (see Table 3).

Suggesting reality testing experiments Have the client practice an experiment with acase manager, a trusted friend or familymember, and ask the client to reportfindings at the next session. Note: it isimportant to have a good understanding ofthe client’s beliefs before proposing areality check.

For a client who believes everyone looks athim when he enters a store, ask the clientto briefly enter a store, look directly atothers in the store, and leave- record theexperience and review in session.

Reducing relapse Develop a relapse plan that builds on clientstrengths. The goal of the plan is to createa written document that the client canrefer to when feeling vulnerable or whensymptoms begin to feel unmanageable.This type of plan is common in the fieldof addiction and is not unique to CBT-P.

“You have made so much progress. Maybewe could write down some of the thingsthat really helped you, like the bestcoping strategies and people whosupported you. Maybe we could alsoidentify the ways to tell if you arebeginning to have problems again.”

Note. Sources: Rector and Beck (2001); Kingdon and Turkington (2005).


Where the psychotic symptoms were often thought of as cate-gories (normal vs. abnormal), the CBT-P clinician begins with theviewpoint that all beliefs/experiences fall on a continuum (Garety& Freeman, 1999). This perspective on symptoms places them ina less stigmatizing context and allows for movement on a contin-uum. The approach to working with the client involves a willing-ness to listen to the client’s concerns/symptoms without prejudg-ments. For example, the client who reports a bizarre delusion orhallucination may be reluctant to talk at all about their concerns forvarious reasons (e.g., fearing hospitalization or rejection). If theydo talk, they may perceive questions about their concerns or effortsby others to point out the “reality” of the situation as threateningor invalidating their experience.

The CBT-P approach also involves openness to modifying ses-sion time, place, and format to allow the client a sense of safety,support, and freedom to begin to talk about and then to eventuallythink differently about their experience. In this sense, the strategiesused in CBT and CBT-P are quite similar, but the perspectivetoward symptoms and the manner in which the clinician workswith the client is unique.

From the standpoint of the clinician, a reasonable question maybe, “How do I respond to a client who adamantly believes apatently bizarre experience?” or “If I explore this experience, willthis reinforce the symptom?” Clearly, the therapist needs to avoidcollusion (i.e., completely agreeing with the client) and use tech-niques that focus solely on the client. The therapist can useSocratic questions to explore aspects of the belief or experiencethat the client may not have considered. For example, if a clientstates that voices tell him/her that neighbors are evil and want toharm him or her, the clinician may ask peripheral questions thatstart with what (e.g., “What does the neighbor do that leads you tobelieve he is evil?”), how (e.g., “How does this neighbor act thatconcerns you?”), when (e.g., “When you see the neighbor, whatdoes he do, what else is going on at that time?”), or where (e.g.,“Where do you typically see this neighbor?”). The use of periph-eral questions shows interest and concern and provides the clientwith ways to identify inconsistency in their beliefs. From ourclinical experience, many treatment providers inquire about theseexperiences in order to make a diagnosis (i.e., are the beliefslogical and based in reality). It appears that far fewer engage inopen discussion about the client’s experience of voices or delu-sions after the diagnosis has been made. In fact, it is not uncom-mon for practitioners to guide their clients to wait for the medi-cation to work and to ignore voices rather than talk about them(Corstens, Escher, & Romme, 2008).

If we agree that it is both important and worthwhile to discussa client’s perceptions and beliefs (however distorted), shouldn’tthe goal and approach be to try and introduce more reality basedthinking? The answer is a qualified “yes,” but the approach is notpredictable and often calls for creativity and the ability to managea great deal of uncertainty. The CBT-P approach generally beginswith the client’s concerns and trying to understand their world asthey experience it. This can be highly anxiety provoking as wetemporarily suspend our reality monitors and try to understand avery frightening experience. With psychosis, the links betweenthoughts, voices, delusions, and external events are often obscuredby cognitive processing deficits (e.g., attention and memory),safety and avoidance behaviors, and the cumulative effects ofsocial isolation. These factors and others (e.g., discomfort with the

psychotic content, worries about personal safety) may lead thera-pists to move quickly to reality-based conclusions for the clientand perhaps inadvertently move at a faster pace than the client.

Although the therapeutic alliance is a core component in alltherapies, gaining trust from an individual diagnosed with schizo-phrenia is often a gift to the clinician, not an entitlement. In aneffort to deal with these challenges, engagement strategies havebeen proposed by a variety of authors to facilitate the therapeuticalliance with a person who is experiencing psychotic symptoms.See Table 3 for a summary list of suggestions and examples.

Normalizing Rationale

One approach used during the early stages of engaging clients isto normalize the symptoms of psychosis. For example, telling theclient that psychotic symptoms are not uncommon (Van Os, Hans-sen, Bijl, & Vollebergh, 2001) or talking about famous people whohave publicly disclosed that they hear voices (e.g., the actorAnthony Hopkins or Brian Wilson from the musical group TheBeach Boys) and have learned how to cope with them. Thestrategy was first described by Kingdon and Turkington (1991)and involves a dialogue with clients around the relative common-ness of unusual experiences like hearing voices or paranoidthoughts (e.g., during sleep deprived states, bereavement) and arationale for understanding the onset of symptoms (e.g., provide anexample of the stress-vulnerability model; Zubin & Spring, 1979).

For example, it might be helpful to let the client know thatexperiences like hearing voices or feeling oversensitive and irri-table are not uncommon in relation to certain stressors like sleepdeprivation, the loss of someone close, or in response to trauma.This can lead to a discussion of how stress can contribute to bothphysical (e.g., headaches) and emotional/psychological (e.g., anx-iety, paranoia) consequences. This conversation can then naturallytransition to looking at current stressors and methods for coping.Discussing symptoms in this way is presumably less stigmatizing(i.e., helping the client to not equate voices with automaticthoughts like “madness” or being “institutionalized”) and begins tointroduce the idea of alternative explanations of symptoms that aregrounded in more common experiences.

This strategy is not unlike information/education provided tothose who experience panic attacks in an effort to help “de-catastrophize” a client’s misinterpretation of physical sensations/cues (Barlow & Craske, 2007). Using this analogy places somesymptoms of psychosis in the same context as anxiety disorders,which also serves to reduce stigma and normalize symptoms.

Dudley et al. (2007) reviewed summary information (sessionratings) pertaining to CBT-P techniques used by therapists in theSensky et al. (2000) study. They divided participants into respond-ers and nonresponders to CBT-P interventions. They found that theindividual techniques (based on individual item analyses and cor-rected for multiple comparisons) that significantly differentiatedresponders from nonresponders included education about schizo-phrenia and clinician self-disclosure (e.g., the therapist might tellthe client that when he only gets 2 hours of sleep, he is irritable andquick to read into what others say about him). When sets of itemswere combined into categories, the authors reported significantlymore items for responders in the “relationship” category (e.g., thetherapist is able to engage the client and form a therapeutic alliancewhich leads to a collaborative approach, d � 1.18) and the “for-


mulation” category (e.g., the therapist and the client explore theonset of symptoms and the surrounding events, discuss currentbeliefs and ways that they are maintained to develop a sharedunderstanding of the problem, d � 1.40). The authors interpretedthe results to support the notion that normalizing symptoms as partof the engagement and formulation process is beneficial for indi-viduals who experience psychotic symptoms. However, due to thesmall sample size, their results are speculative and await furtherinvestigation.

Formulation

The goal of collaboratively developing a shared understandingof the client’s concerns is fundamental to all forms of CBT. Toreiterate the discussion from the engagement section, the sharedmodel can include unusual content, expectations, and so forth. It isimportant to fully hear the client’s rationale before moving toaction. Otherwise, the client may perceive their concerns to beinvalidated. Taking it one step further, CBT-P emphasizes theimportance of the client arriving at their own conclusions aboutbeliefs and perceptions (through Socratic dialogue, guided discov-ery and checking). This lays the groundwork for a transition toschema work, which is also common to traditional CBT.

The concept of schema work in CBT-P is similar to traditionalCBT; however, there are some areas of difference. One issueinvolves the pace and degree of affect that can be generated whenattempting to identify a core belief (e.g., by way of downwardarrow technique). Kingdon and Turkington (2005) advise that

work on schemas may be helpful, but to be careful not to activatetoo much distress. If a client becomes visibly distressed, it is oftenadvisable to refocus the discussion to other topics.

A second issue involves determining the basis of a core belief(i.e., on a continuum from purely psychotic content to beliefs thatare rooted in experience). For example, a client may have experi-enced a pleasant childhood with supportive family and friendsbefore the first psychotic break but contends with voices that arecritical and unrelenting, telling the client that he is evil and no oneloves him. From a formulation and schema standpoint, the clini-cian may work with the client to examine the voice content (e.g.,“do you believe what the voices say?”) and explore client’s auto-matic thoughts and assumptions in relation to the voice content(e.g., “can we look at the reasons you believe that?”). This caninclude developing a list of reasons for and against the voicecontent. This process may also reveal a client’s core belief abouthow lovable/unlovable they believe they are and what factorsinfluence this belief (e.g., past experiences of rejection vs. voicecontent unrelated to past experience or influenced by actual eventsthat are misinterpreted). If the voice content and core belief arerelated to past experience, then the work with the client may focuson continuums (loveable to unlovable) and techniques such aspositive data logs as in standard CBT (keeping in mind the issuerelated to distress). If the voice content/beliefs are based on inac-curate information (e.g., the voice is calling the client the devil),the direction of the therapy may be to help the client to gatherevidence to disprove the voice content (see Nelson, 2005 for a

Table 3Suggestions to Improve Alliance/Engagement

Suggestion Example

Use simple, honest, and accurate communication. “When you have a lot of stress and you don’t sleep, it seems likethe voices get worse” vs. “the voices are due to a bio-chemicalimbalance in your neurotransmitters.”

When asking about symptoms, be guided by a healthy curiosity. Do notcollude with the delusion.

If a client believes that he or she is being followed, ask fordetails: “Do you know who is following you? What do youthink the person wants? Does this person follow you all of thetime?”

Restrict the use of silence because it may lead to discomfort for theclient.

“I noticed that you have been quiet. Is there anything on yourmind that you would like to talk about? If not, how would youlike to talk about other things in your life?” (at this point, drawon information about client that you have obtained – hobbies,interests, more neutral topics).

Depending on the client, the clinician may need to be flexible about thelocation of therapy. Instead of a face-to-face session, use creativity.If a session is held outside of the office, the clinician must ensurethat privacy and confidentiality are maintained.

Be flexible and open to walking with the client, getting coffee, gowhere the client is comfortable. Consider providing sessions ina client’s group home or residence.

If the client becomes upset during the discussion, it is advisable tochange to a more neutral topic and allow the client time to calm self(“tactical withdrawal”).

“It looks like this topic is upsetting. What if we save thisdiscussion for another time and talk about something else for alittle bit?” As above, change the topic of conversation tohobbies, current affairs, or interests.

Use shorter session times. The client may not be able to tolerate atraditional 50-minute session. During the first meeting, the client andclinician discuss both the length and frequency of sessions.

Monitor the client’s ability to remain engaged: is the client able tosit still, does the client appear to be internally stimulated, doesthe client respond to questions? The clinician could ask, “Inotice that it can be harder to stay focused if we sit too long.As far as how long we will meet, what would yourecommend?”

Be reliable, predictable, and dependable. Be consistent in interactions with clients, and keep regularlyscheduled appointments.

Note. Sources: Chadwick et al., 1996; Garfield and Mackler, 2009; Kingdon and Turkington, 2005; Nelson, 2005.


more complete discussion of ways to modify beliefs that influenceor underlie voices or delusions).

Coping Strategies

As with all individuals who experience symptoms of mentalillness, people who experience symptoms of psychosis find waysto cope with their symptoms. Carr (1988) surveyed a wide range ofindividuals with schizophrenia in order to identify how they copedwith symptoms. The results identified a variety of techniques thatwere often linked to the role of attention. More specially, themajority of techniques included redirection of attention in somefashion, with or without using external aids. For example, clientschose to listen to music, play with pets, or simply leave theimmediate environment to engage in an activity like windowshopping. Tarrier et al. (1990) developed Coping Strategy En-hancement from clinical and research experience. Similar to Carr’swork, some techniques use distraction or redirection of attention(e.g., increasing activity or listening to music), while others fo-cused on coping with positive (i.e., hallucinations and paranoia)symptoms (e.g., using a diary to track when voices occur and whatthey are saying).

The process is generally collaborative, often involving self-monitoring and selection of targets based on potential for successor reduction of symptoms (see Tarrier, Beckett, Harwood, Baker,Yusupoff, & Ugarteburu, 1993; Tarrier, Sharpe, Beckett, et al.,1993). For example, if the client reports that she would like to copebetter with voices, she may be encouraged to record the voices(e.g., time of day, intensity, content, what the client is doing) fora period of time and bring the record to session. The therapist andclient then work together to identify patterns that may exacerbatesymptoms (e.g., the voices get louder when the client is alone) andcoping strategies that may minimize distress (e.g., go to a friend’shouse or phone a friend when the client feels lonely). Informationfrom the self-monitoring form (voice diary) may also point outpotential coping ideas. For example, based on this information, thetherapist may say, “it seems like the voices were less loud andbothersome when listening to different kinds of music; would it behelpful to check this out during the next week or two?” Betweensession work, or homework, can then be suggested as a way to testout a coping idea. Successful strategies can then be recorded (e.g.,on a card) to facilitate recall and regular application.

Working from a coping skills framework allows the clinician theflexibility to either draw from a variety of coping ideas that othershave found effective and offer them to clients for their review orcollaborate with clients to develop more individualized copingideas. If, after reviewing a list of coping strategies that other clientshave found effective, the client is unable to identify a specificstrategy, the clinician works with the client to find strategies thathave worked for the client in the past or explore strategies that theclient is willing to test out. For example, if the client enjoyedriding a bike before the first episode of psychosis, the clinicianwould encourage the client to engage in this activity betweensessions. The goal of this activity is to elicit hope and move theclient’s focus away from psychosis. This dimension of CBT-Paims to help the client feel more empowered by gaining somecontrol over distressing symptoms. Overall, there appears to be noclear advantage to using distraction-based coping strategies com-pared to focusing-based coping strategies (Haddock, Slade, Ben-

tall, Reid, & Faragher, 1998; see Table 4 for examples of each typeof strategy).

Behavioral Experiments

Behavioral experiments are a common practice in traditionalCBT. Experiments or tests are developed to investigate the accu-racy of certain attitudes and beliefs. In contrast to consideringalternative explanations for events (typically done during session),this approach asks the client and therapist to collectively identifysome action that would provide evidence for and against certainbeliefs. For example, if the client believes that the voices keep himor her up at all hours of the night, the client may be encouraged touse a voice-activated recorder that can be left on all night andbrought to the next session for review.

Overall, clients are asked to concretely test out certain ideaswith actions that can be processed during the next session. Eachtest is tailored to client need. For example, consider a client whoexperiences paranoia when entering a crowded room (e.g., “every-one looks at me and criticizes me”) and therefore avoids goingplaces (increasing social isolation). After laying the groundworkabout normalizing anxiety and considering alternative reasonsothers may have for looking at people in public, the clinician canask the client to check out her thoughts. The client may be asked tostep into a crowded room (with a trusted friend by her side) for a shortperiod of time, intentionally look around the room at each person,leave the room, and record findings in a diary (e.g., what was ob-served, how many people looked at her, their response, differentreasons for people’s actions) to process at the next session.

A great deal of creativity and finesse is required to help theclient devise an adequate test of a belief that is meaningful,corrective, and not overwhelming. The challenge with cases in-volving psychosis is to introduce the “test” only when the client isready. Although there are no clear guidelines here, it is importantto listen for subtle areas of doubt voiced by the client and to moveslowly. Therapists can be lured into pouncing on early signs ofdoubt and devising the one test that will “prove” to the client theyare incorrect in their beliefs, and this failure in “timing” is seen asunhelpful to the treatment process. It is often more helpful to thinkin terms of a progression of tests that are developed with the client.It may be helpful to first develop a test that challenges peripheralelements of a delusion and then slowly progress to more persuasiveexperiments. For example, if the client believes they are controlled bya device, it may be useful to first ask the client to look for information(via Internet or book) on how a device like this works and to bring theinformation to the next session for review.

Summary

In summary, our review of CBT-P for positive symptoms ofpsychosis demonstrates a modest, but significant positive im-pact (average effect around .35–.40) in controlled studies.When compared with an active therapy control, the benefits ofCBT-P are limited (average effect around .20). There is no clearevidence that CBT-P provides a significant advantage in pre-venting relapse when this term is broadly defined. When relapseprevention is defined strictly by rate of rehospitalization, stud-ies have been mixed in outcomes. However, there are somepromising results that clients who have engaged in CBT-P


interventions may spend less time in the hospital relative toclients who receive only standard care (Malik et al., 2009).

Looking at specific symptoms, CBT-P for hallucinations appears toprovide some benefits during the treatment phase that may be lost atextended follow-up (i.e., when no longer in active treatment) in manybut not all studies. However, CBT-P combined with other interven-tions (e.g., including family in treatment, motivational interviewing,assertive crisis intervention) for hallucinations shows promise formaintaining gains over time (Jenner et al., 2006). For delusions, thePfammatter et al. (2006) review suggested that the benefits of CBT-Pfor delusions take longer to emerge (i.e., often do not see significantchanges until several months after treatment at a follow-up assess-ment). CBT-P for negative symptoms showed modest benefits acrossstudies using TAU and active control groups (Wykes et al., 2008) andno benefit when compared with studies only using active therapycontrols (see Lynch et al., 2010). Some studies also suggest potentiallong-term benefits of CBT-P with regard to negative symptoms (seeTurkington et al., 2008).

This review also suggested modest benefits of CBT-P during theacute phase. Although there is some potential for CBT-P to facilitatethe speed of recovery during an acute episode, this finding has notbeen adequately established. Also of note, clients who receive CBT-Pconsistently report high levels of satisfaction with this approach.Overall, based on this review of the literature, the use of CBT-P inclinical practice appears to hold promise as an effective treatment forindividuals who experience persistent psychotic symptoms, but fur-ther evaluation in the key areas identified above is recommended.

Recommendations for Theory and Research

We believe that future research focused on understanding theimpact of engagement strategies on early treatment gains is war-ranted, more precisely, the specific impact of therapeutic alliance.In highly controlled studies, those who provided therapy to controlgroups were often the same individuals who delivered CBT-P.Although the therapists in the control condition could not use

Table 4Types of Coping Strategies for Hallucinations

Distraction Example

Listening to music or radio talk shows “Let’s talk about different types of radio stations that you listen to.Is there a certain type of music or talk show that makes you feelcalm? After looking at the voice diary that you completed, itlooks like 5:00 PM is when the voices start getting bad. Do youthink you could turn on the radio at that time to help you staycalmer?”

Meditation Technique: Teach the client a technique like guided imagerywhere they can create a “safe place.”

“Close your eyes and imagine a place where you have been whereyou have felt peaceful, or think of a vacation spot that youwould like to visit. Imagine that you are there. What do you see?What do you hear? What do you smell . . . .”

Have the client choose an activity (e.g., playing a game, painting,working on a computer).

“I noticed that you have mentioned a few times that you enjoypainting. Do you think that when the voices act up, you couldpick up a paint brush and start painting?”

Phoning a friend: Ask the client to set up a support network (e.g.,family member or friend) to call when the voices occur.

“You have said that when you talk to people, the voices go away.The next time the voices bother you, would you be willing tocall your mom?”

Exercise: Set a reasonable exercise routine with the client. For example,if the client has not exercised for years, ask him or her to take abrief walk and slowly increase time increments.

“It seems like the voices don’t bother you when you are walking.Do you think it would help to put on your shoes and take a walkthe next time they act up?”

Focusing ExampleSubvocalization: Go through the mental process of generating speech

but not actually saying it aloud; read quietly to self; talk on cell-phone.

“The next time you are in public and the voices start botheringyou, would it be possible to pick up your cell phone, pretend thatsomeone is on the other end, and just talk quietly to yourselfabout the weather?”

Respond rationally to the voice. Work with the client to minimize the emotional impact of the voicefirst and assist the client in developing a calm response. (e.g.,“That is not true,” “You have no power over me”).

Ask the client to set aside a specified time each day to listen to thevoices. The amount of time (e.g., 20 or 30 minutes) is determined bythe client.

“You have noticed that the voices are pretty bad during the latemorning. Would you be willing to set aside one time each day(for about 20 minutes) when you will listen to the voices? Thatway, when they bother you at different times of the day, you cantell them to come back at a certain time and not feel that youhave to focus on them throughout the day.”

Use normalizing explanation. “When the voices are acting up can you remind yourself that otherpeople also hear voices, especially under stress, and that they area symptom of the illness and do not have power over you?”

Use voice diary to identify patterns. Ask the client to record when the voices occur, voice content, whatthe client is physically doing at the specified time(s), ratings ofdistress and coping ideas. The client would bring the diary intosession for review.

Note. Sources: Haddock et al. (1998); Kingdon and Turkington (2005).


specific CBT-P techniques, they were encouraged and trained toengage clients in a supportive and accepting way. Therapeuticengagement tailored for psychosis, plus some shared activity, maycontribute to initial benefits for both conditions. Beyond generaltherapeutic factors, it will be important to clarify the specificelements of CBT-P which may influence positive change. Forexample, Wykes et al. (2008) point to “a trend for CBT-P modelsto emphasize more behavior aspects of treatment to promote largereffective sizes” (p. 534). It will be important to further investigatewhich models and techniques most influence improvements. Froma methodological standpoint, future studies of CBT-P should alsoattend to issues that could impact outcomes such as blinding ratersto treatment condition, the use of active therapy controls, andfollow-up assessments several months posttreatment.

Based on research evidence conducted in routine practice settingsand the cost of training individuals in CBT-P, several authors (Farhallet al., 2009; Garetyet al., 2008; Peters et al., 2010) suggested thatCBT-P be recommended for selected patients (e.g., help-seekers)rather than offered to all clients with persistent symptoms. Unfortu-nately, there are no clear guidelines for allocating clients to CBT-P.Based on evidence from this review, clients who report distressrelated to symptoms, show some degree of insight or flexibility inthinking, and express desire for treatment will likely be good choicesfor CBT-P. More work is needed in this area.

One issue that we also believe deserves further discussion ishow we define significant change (see also Tarrier et al., 1993).Given the wide range of distress and impairment in functioningthat can occur with a psychotic illness, it may make sense to extendthe view of change to go beyond symptom improvement. Manytimes, a common assessment protocol (e.g., PSYRATS, PANSS)does not capture the smaller, idiosyncratic changes that can movea client toward recovery. A closer look at qualitative differences(e.g., trusting a clinician, talking about symptoms, coming to theagency regularly, taking medication) may provide insight intochanges that seem to occur after treatment has been completed forsome clients receiving CBT-P. Furthermore, looking closer at howwe define positive change may reveal other areas or processes thatare important to promoting recovery from a psychotic illness.

The question of who can deliver this type of intervention opensup numerous possibilities. In the majority of studies, CBT-P isdelivered by expert psychologists, advanced practice nurse/therapists, and in some cases psychiatrists. The role of nonexpertsin delivering CBT-P is not clear. Although some authors indicatedthat CBT-P given by nonexperts did not show a positive effect inroutine practice (Farhall et al., 2009), others reported positivefindings in practice settings when nonexperts provided CBT-P(Morrison et al., 2004; Peters et al., 2010). For example, one study(Turkington et al., 2002) demonstrated that various techniqueswithin CBT-P can also be provided by individuals without ad-vanced training with positive results. Other studies (Rollinson etal., 2007; Pinniniti, Fisher, Thompson, & Steer, 2010) also de-scribe a broad range of mental health workers using CBT-P tech-niques in different settings. The role of nonexperts in providingCBT-P requires further investigation.

In conclusion, both the PORT and NICE guidelines recommendthat CBT-P be considered for individuals who experience schizophre-nia. How do we make this type of service more available in the UnitedStates, and who can provide this type of service? Some of thechallenges faced by community mental health systems in the United

States include the way services are reimbursed, ways to reach out andengage individuals diagnosed with schizophrenia in treatment ser-vices, and workforce development issues. Innovation may be requiredto reach this population through personnel and methods that are notcurrently in place. Finally, at the present time, there are very fewoptions for training and supervision in CBT-P, and most options areavailable only outside the United States. Clearly, it is important tocontinue to think about how to implement effective therapeutic ad-juncts to medication interventions in order to promote recovery forthose who are faced with this challenging illness.

References

Andreasen, N. C. (1981). Scale for assessment of negative symptoms. IowaCity, IA: University of Iowa.

Beck, A. T., Rector, N. A., Stolar, N., & Grant, P. (2009). Schizophrenia:Cognitive theory, research, and therapy. New York: Guilford PressPublications Guilford Press.

Brabban, A., Tai, S., & Turkington, D. (2009). Predictors of outcome inbrief cognitive behavior therapy for schizophrenia. Schizophrenia Bul-letin, 35, 859–864. doi:10.1093/schbul/sbp065

Carr, V. (1988). Patients’ techniques for coping with schizophrenia: Anexploratory study. British Journal of Medical Psychology, 61, 339–352.doi:10.1111/j.2044-8341.1988.tb02796.x

Chadwick, P., Birchwood, M. J., & Trower, P. (1996). Cognitive therapyfor delusions, voices and paranoia. New York: Wiley.

Barlow, D. H., & Craske, M. G. (2007). Mastery of your anxiety and panic(4th ed.). New York: Oxford University Press.

Cohen, J. (1988). Statistical power and the behavioral sciences (2nd ed.).Hillsdale, NJ: Erlbaum.

Corstens, D., Escher, S., & Romme, M., (2008). Accepting and workingwith voices: The Maastricht approach. In A. Moskowitz, I. Schafer, &M. J. Dorahy (Eds.), Psychosis, trauma, and dissociation: Emergingperspectives on severe psychopathology (p. 321). Chichester, UnitedKingdom: Wiley-Blackwell.

David, A., Buchanana, A., Rees, A., & Almeida, O. (1992). The assess-ment of insight in psychosis. British Journal of Psychiatry, 161, 599–602. doi:10.1192/bjp.161.5.599

Deegan, P. (1997). Recovery as a journey of the heart. In L. Spaniol, C.Gagne, & M. Koehler (Eds.), Psychological and social aspects ofpsychiatric disability. Boston, MA: Boston University Press.

Dixon, L. B., Dickerson, F., Bellack, A. S., Bennett, M., Dickinson, D.,Goldberg, R. W., . . . Kreyenbuhl, J. (2010). The 2009 schizophreniaPORT psychosocial treatment recommendations and summary state-ments. Schizophrenia Bulletin, 36, 48–70. doi:10.1093/schbul/sbp115

Drury, V., Birchwood, M., Cochrane, R., & Macmillan, F. (1996a). Cog-nitive therapy and recovery from acute psychosis: A controlled trial: I.Impact on psychotic symptoms. British Journal of Psychiatry, 169,593–601. doi:10.1192/bjp.169.5.593

Drury, V., Birchwood, M., Cochrane, R., & Macmillan, F. (1996b). Cog-nitive therapy and recovery from acute psychosis: A controlled trial: II.Impact on recovery time. British Journal of Psychiatry, 169, 602–607.doi:10.1192/bjp.169.5.602

Dudley, R., Bryant, C., Hammond, K., Siddle, R., Kingdon, D., & Turk-ington, D. (2007). Techniques in cognitive behavioural therapy: Usingnormalizing in schizophrenia. Journal of the Norwegian PsychologicalAssociation, 44, 562–572.

Durham, R. C., Guthrie, M., Morton, R. V., Reid, D. A., Treliving, L. R.,Fowler, D., & Macdonald, R. R. (2003). Tayside-Fife clinical trial ofcognitive-behavioural therapy for medication-resistant psychotic symp-toms. Results to 3-month follow-up. British Journal of Psychiatry, 182,303–311. doi:10.1192/bjp.182.4.303

Farhall, J., Freeman, N. C., Shawyer, F., & Trauer, T. (2009). An effec-


tiveness trial of cognitive behaviour therapy in a representative sampleof outpatients with psychosis. British Journal of Clinical Psychology,48, 47–62. doi:10.1111/j.2044-8260.2009.tb00456.x

Fowler, D. R., Garety, P. A., & Kuipers, L. (1995). Cognitive behaviourtherapy for psychosis: Theory and practice. New York: Wiley.

Garety, P., Fowler, D., Kuipers, E., Freeman, D., Dunn, G., Bebbington, P.,. . . Jones, S. (1997). London-East Anglia randomised controlled trial ofcognitive-behavioural therapy for psychosis. Part II: Predictors of out-come. British Journal of Psychiatry, 171, 420 – 426. doi:10.1192/bjp.171.5.420

Garety, P. A., Fowler, D. G., Freeman, D., Bebbington, P., Dunn, G., &Kuipers, E. (2008). Cognitive–behavioural therapy and family interven-tion for relapse prevention and symptom reduction in psychosis: Ran-domised controlled trial. British Journal of Psychiatry, 192, 412–423.doi:10.1192/bjp.bp.107.043570

Garety, P. A., & Freeman, D. (1999). Cognitive approaches to delusions:A critical review of theories and evidence. British Journal of ClinicalPsychology, 38, 113–154. doi:10.1348/014466599162700

Garfield, D., & Mackler, D. (Eds.). (2009). Beyond medication: Therapeu-tic engagement and the recovery from psychosis. New York: Routledge.

Gould, R. A., Mueser, K. T., Bolton, E., Mays, V., & Goff, D. (2001).Cognitive therapy for psychosis in schizophrenia: An effect size analy-sis. Schizophrenia Research, 48, 335–342.

Grant, P. M., & Beck, A. T. (2009). Defeatist beliefs as a mediator ofcognitive impairment, negative symptoms, and functioning in schizo-phrenia. Schizophrenia Bulletin, 35, 798 – 806. doi:10.1093/schbul/sbn008

Grant, P. M., Huh, G. A., Perivoliotis, D., Stolar, N. M., & Beck, A. T.(2012). Randomized trial to evaluate the efficacy of cognitive therapyfor low-functioning patients with schizophrenia. Archives of GeneralPsychiatry, 69, 121–127. doi:10.1001/archgenpsychiatry.2011.129

Haddock, G., Barrowclough, C., Shaw, J. J., Dunn, G., Novaco, R. W., &Tarrier, N. (2009). Cognitive-behavioural therapy v. social activity ther-apy for people with psychosis and a history of violence: Randomisedcontrolled trial. British Journal of Psychiatry, 194, 152–157. doi:10.1192/bjp.bp.107.039859

Haddock, G., McCarron, J., Tarrier, N., & Faragher, E. B. (1999). Scalesto measure dimensions of hallucinations and delusions: The psychoticsymptom rating scales (PSYRATS). Psychological Medicine, 29, 879–889. doi:10.1017/S0033291799008661

Haddock, G., Slade, P. D., Bentall, R. P., Reid, D., & Faragher, E. B.(1998). A comparison of the long-term effectiveness of distraction andfocusing in the treatment of auditory hallucinations. British Journal ofMedical Psychology, 71, 339 –349. doi:10.1111/j.2044-8341.1998.tb00996.x

Haddock, G., Tarrier, N., Morrison, A. P., Hopkins, R., Drake, R., &Lewis, S. (1999). A pilot study evaluating the effectiveness of individualinpatient cognitive-behavioral therapy in early psychosis. Social Psychi-atry and Psychiatric Epidemiology, 34, 254 –258. doi:10.1007/s001270050141

Jackson, H. J., McGorry, P. D., Killackey, E., Bendall, S., Allot, K.,Dudgeon, P., Gleeson, J., Johnson, T., & Harrigan, S. (2008). Acute-phase and 1-year follow-up results of a randomized controlled trial ofCBT versus Befriending for first-episode psychosis: The ACE project.Psychological Medicine, 38, 725–735. doi:10.1017/S0033291707002061

Jakes, S., Rhodes, J., & Turner, T. (1999). Effectiveness of cognitivetherapy for delusions in routine clinical practice. British Journal ofPsychiatry, 175, 331–335. doi:10.1192/bjp.175.4.331

Jenner, J. A., Nienhuis, F. J., Van De Willige, G., & Wiersma, D. (2006).“Hitting” voices of schizophrenia patients may lastingly reduce persis-tent auditory hallucinations and their burden: 18-month outcome of arandomized controlled trial. Canadian Journal of Psychiatry, 51, 169–177.

Jenner, J. A., Nienhuis, F. J., Wiersma, D., & Van De Willige, G. (2004).Hallucination focused integrative treatment: A randomized controlledtrial. Schizophrenia Bulletin, 30, 133–145. doi:10.1093/oxfordjournals.schbul.a007058

Kay, S. R. (1991). Positive and negative syndromes in schizophrenia. NewYork: Bruner/Mazel.

Kingdon, D. (2010). Over-simplification and exclusion of non-conformingstudies can demonstrate absence of effect: A lynching party? Psycho-logical Medicine, 40, 25–27. doi:10.1017/S0033291709990201

Kingdon, D. G., & Turkington, D. (1991). Preliminary report: The use ofcognitive behavior therapy and a normalizing rationale in schizophrenia.Journal of Nervous and Mental Disease, 179, 207–211. doi:10.1097/00005053-199104000-00005

Kingdon, D. G., & Turkington, D. (1994). Cognitive-behavioral therapy ofschizophrenia. New York: Guilford Press.

Kingdon, D. G., & Turkington, D. (2005). Cognitive therapy of schizo-phrenia. New York: Guilford Press.

Kuipers, E., Fowler, D., Garety, P., Chisholm, D., Freeman, D., Dunn, G.,Bebbington, P., & Hadley, C. (1998). London-East Anglia randomizedcontrolled trial of cognitive-behavioural therapy for psychosis III:Follow-up and economic evaluation at 18 months. British Journal ofPsychiatry, 173, 61–68. doi:10.1192/bjp.173.1.61

Kuipers, E., Garety, P., Fowler, D., Dunn, G., Bebbington, P., Freeman, D.,& Hadley, C. (1997). London-East Anglia randomised controlled trial ofcognitive-behavioural therapy for psychosis. I: Effects of the treatmentphase. British Journal of Psychiatry, 171, 319 –327. doi:10.1192/bjp.171.4.319

Lewis, S., Tarrier, N., Haddock, G., Bentall, R., Kinderman, P., Kingdon,D., . . . Dunn, G. (2002). Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: Acute-phase outcomes. Brit-ish Journal of Psychiatry, 181 Suppl 43, s91–s97. doi:10.1192/bjp.181.43.s91

Lukoff, D., Liberman, R. P., & Nuechterlein, K. H. (1986). Symptommonitoring in the rehabilitation of schizophrenic patients. SchizophreniaBulletin, 12, 578–602.

Lynch, D., Laws, K. R., & McKenna, P. J. (2010). Cognitive behaviouraltherapy for major psychiatric disorder: Does it really work? A meta-analytical review of well-controlled trials. Psychological Medicine, 40,9–24. doi:10.1017/S003329170900590X

Malik, N., Kingdon, D., Pelton, J., Mehta, R., & Turkington, D. (2009).Effectiveness of brief cognitive-behavioral therapy for schizophreniadelivered by mental health nurses: Relapse and recovery at 24 months.Journal of Clinical Psychiatry, 70, 201–207. doi:10.4088/JCP.07m03990

Morrison, A. P., Renton, J. C., Williams, S., Dunn, H., Knight, A., Kreutz,M., . . . Dunn, G. (2004). Delivering cognitive therapy to people withpsychosis in a community mental health setting: An effectiveness study.Acta Psychiatrica Scandinavica, 110, 36 – 44. doi:10.1111/j.1600-0447.2004.00299.x

Naeem, F., Kingdon, D., & Turkington, D. (2008). Predictors of responseto cognitive behaviour therapy in the treatment of schizophrenia: Acomparison of brief and standard interventions. Cognitive Therapy andResearch, 32, 651–656. doi:10.1007/s10608-008-9186-x

National Collaborating Centre for Mental Health. (2009) Schizophrenia:Core interventions in the treatment and management of schizophrenia inadults in primary and secondary care (p. 41). . London (UK): NationalInstitute for Health and Clinical Excellence (NICE). NICE clinicalguideline; no. 82.

Nelson, H. E. (2005). Cognitive-Behavioural therapy with delusions andhallucinations: A practice manual (2nd ed.). Cheltenham, UK: NelsonThornes.

Overall, J. E., & Gorham, D. R. (1962). The brief psychiatric rating scale.Psychological Reports, 10, 799–812.


Perivoliotis, D., & Cather, C. (2009). Cognitive Behavioral Therapy ofnegative symptoms. Journal of Clinical Psychology, 65, 815–830.

Peters, E., Landau, S., McCrone, P., Cooke, M., Fisher, P., Steel, C., . . .Kuipers, E. (2010). A randomised controlled trial of cognitive behaviourtherapy for psychosis in a routine clinical service. Acta PsychiatricaScandinavica, 122, 302–318. doi:10.1111/j.1600-0447.2010.01572.x

Pfammatter, M., Junghan, U. M., & Brenner, H. D. (2006). Efficacy ofpsychological therapy in schizophrenia: Conclusions from meta-analyses. Schizophrenia Bulletin, 32 Suppl 1, S64–S80. doi:10.1093/schbul/sbl030

Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G.,& Morgan, C. (2002). Psychological treatments in schizophrenia: I.Meta-analysis of family intervention and cognitive behaviour therapy.Psychological Medicine, 32, 763–782. doi:10.1017/S0033291702005895

Pinninti, N. R., Fisher, J., Thompson, K., & Steer, R. (2010). Feasibilityand usefulness of training assertive community treatment team in cog-nitive behavioral therapy. Community Mental Health Journal, 46, 337–341. doi:10.1007/s10597-009-9271-y

Rector, N. A., Beck, A. T., & Stolar, N. (2005). The negative symptoms ofschizophrenia: A cognitive perspective. Canadian Journal of Psychiatry,50, 247–257.

Rector, N. A., & Beck, A. T. (2001). Cognitive behavioral therapy forschizophrenia: An empirical review. Journal of Nervous and MentalDisease, 189, 278–287. doi:10.1097/00005053-200105000-00002

Rollinson, R., Haig, C., Warner, R., Garety, P., Kuipers, E., Freeman, D.,. . . Fowler, D. (2007). The application of cognitive-behavioral therapyfor psychosis in clinical and research settings. Psychiatric Services, 58,1297–1302. doi:10.1176/appi.ps.58.10.1297

Sensky, T., Turkington, D., Kingdon, D., Scott, J. L., Scott, J., Siddle, R.,. . . Barnes, T. R. (2000). A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant tomedication. Archives of General Psychiatry, 57, 165–172. doi:10.1001/archpsyc.57.2.165

Shawyer, F., Farhall, J., Mackinnon, A., Trauer, T., Sims, E., Ratcliff, K.,. . . Copolov, D. (2012). A randomised controlled trial of acceptance-based cognitive behavioural therapy for command hallucinations inpsychotic disorders. Behaviour Research and Therapy, 50, 110–121.doi:10.1016/j.brat.2011.11.007

Startup, M., Jackson, M. C., & Bendix, S. (2004). North Wales randomizedcontrolled trial of cognitive behaviour therapy for acute schizophreniaspectrum disorders: Outcomes at 6 and 12 months. Psychological Med-icine, 34, 413–422. doi:10.1017/S0033291703001211

Tai, S., & Turkington, D. (2009). The evolution of cognitive behaviortherapy for schizophrenia: Current practice and recent developments.Schizophrenia Bulletin, 35, 865–873.

Tarrier, N., Beckett, R., Harwood, S., Baker, A., Yusupoff, L., & Ugarte-buru, I. (1993). A trial of two cognitive-behavioural methods of treatingdrug-resistant residual psychotic symptoms in schizophrenic patients: I.Outcome. British Journal of Psychiatry, 162, 524–532. doi:10.1192/bjp.162.4.524

Tarrier, N., Harwood, S., Yusopoff, L., Beckett, R., & Baker, A. (1990).Coping Strategy Enhancement (CSE): A method of treating residualschizophrenic symptoms. Behavioural Psychotherapy, 18, 283–293. doi:10.1017/S0141347300010387

Tarrier, N., Lewis, S., Haddock, G., Bentall, R., Drake, R., Kinderman,P., . . . Dunn, G. (2004). Cognitive-behavioral therapy in first-episodeand early schizophrenia: 18 month follow-up of a randomised controlledtrial. British Journal of Psychiatry, 184, 231–239.

Tarrier, N., Kinney, C., McCarthy, E., Wittkowski, A., Yusupoff, L.,Gledhill, A., . . . Humphreys, L. (2001). Are some types of psychoticsymptoms more responsive to Cognitive- Behaviour Therapy? Behav-

ioural and Cognitive Psychotherapy, 29, 45–55. doi:10.1017/S1352465801001060

Tarrier, N., Sharpe, L., Beckett, R., Harwood, S., Baker, A., & Yusopoff,L. (1993). A trial of two cognitive behavioural methods of treatingdrug-resistant residual psychotic symptoms in schizophrenic patients.Part II: Treatment-specific changes in coping and problem-solving skills.Social Psychiatry and Psychiatric Epidemiology, 28, 5–10. doi:10.1007/BF00797826

Tarrier, N., & Wykes, T. (2004). Is there evidence that cognitive behaviourtherapy is an effective treatment for schizophrenia? A cautious orcautionary tale? Behaviour Research and Therapy, 42, 1377–1401.doi:10.1016/j.brat.2004.06.020

Tarrier, N., Yusupoff, L., Kinney, C., McCarthy, E., Gledhill, A., Haddock,G., & Morris, J. (1998). Randomised controlled trial of intensive cog-nitive behavior therapy for patients with chronic schizophrenia. BritishMedical Journal, 317, 303–307. doi:10.1136/bmj.317.7154.303

Trower, P., Birchwood, M., Meaden, A., Byrne, S., Nelson, A., & Ross, K.(2004). Cognitive therapy for command hallucinations: Randomisedcontrolled trial. British Journal of Psychiatry, 184, 312–320. doi:10.1192/bjp.184.4.312

Turkington, D., Kingdon, D., Rathod, S., Hammond, K., Pelton, J., &Mehta, R. (2006). Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental health nurses in schizophrenia. Brit-ish Journal of Psychiatry, 189, 36–40. doi:10.1192/bjp.bp.105.010884

Turkington, D., Kingdon, D., & Turner, T.; the Insight into SchizophreniaResearch, G. (2002). Effectiveness of a brief cognitive-behaviouraltherapy intervention in the treatment of schizophrenia. British Journal ofPsychiatry, 180, 523–527. doi:10.1192/bjp.180.6.523

Turkington, D., Sensky, T., Scott, J., Barnes, T. R., Nur, U., Siddle, R., . . .Kingdon, D. (2008). A randomized controlled trial of cognitive-behaviortherapy for persistent symptoms in schizophrenia: A five-year follow-up.Schizophrenia Research, 98, 1–7. doi:10.1016/j.schres.2007.09.026

Valmaggia, L. R., Van Der Gaag, M., Tarrier, N., Pijnenborg, M., &Slooff, C. J. (2005). Cognitive-behavioural therapy for refractory psy-chotic symptoms of schizophrenia resistant to atypical antipsychoticmedication. Randomised controlled trial. British Journal of Psychiatry,186, 324–330. doi:10.1192/bjp.186.4.324

Van Os, J., Hanssen, M., Bijl, R. V., & Vollebergh, W. (2001). Prevalenceof psychotic disorder and community level of psychotic symptoms: Anurban rural comparison. Archives of General Psychiatry, 58, 663–668.doi:10.1001/archpsyc.58.7.663

Wampold, B. E. (2007). Psychotherapy: The humanistic (and effective)treatment. American Psychologist, 62, 857– 873. doi:10.1037/0003-066X.62.8.857

Wiersma, D., Jenner, J. A., Nienhuis, F. J., & van de Willige, G. (2004).Hallucination focused integrative treatment improves quality of life inschizophrenia patients. Acta Psychiatrica Scandinavica, 109, 194–201.doi:10.1046/j.0001-690X.2003.00237.x

Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behaviortherapy for schizophrenia: Effect sizes, clinical models, and method-ological rigor. Schizophrenia Bulletin, 34, 523–537. doi:10.1093/schbul/sbm114

Zimmermann, G., Favrod, J., Trieu, V. H., & Pomini, V. (2005). The effectof cognitive behavioral treatment on the positive symptoms of schizo-phrenia spectrum disorders: A meta-analysis. Schizophrenia Research,77, 1–9. doi:10.1016/j.schres.2005.02.018

Zubin, J., & Spring, B. (1977). Vulnerability: A new view of schizophre-nia. Journal of Abnormal Psychology, 86, 103–126. doi:10.1037/0021-843X.86.2.103

Received March 21, 2012Accepted March 22, 2012 �


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Cognitive Behavioral Therapy for Psychosis in Clinical Practice